Please type all responses in the application materials ...

1 Please type all responses in the application materials . applications must be mailed. Hand delivery is not Applicant; The following series of documents contain the application materials for a home health Agency. Please note that all questions must be answered, and all requested supporting documentation must be provided. If you fail to submit all requested information, the application materials will be mailed back to you. If your application is in accordance with Pennsylvania home health Agency rules and regulations, the Division of home health will issue you a license.

2 Please keep in mind the length of time for the licensure process depends upon the accuracy of information provided. If it is determined that corrections need made to the information you submitted, an email will be sent to the email address you provide in the application materials . You will be given 30 days from the date of the email to resubmit revisions to your policies. Failure to resubmit in a timely fashion will result in your application being withdrawn from consideration. Sincerely, Division of home health Department of health | Bureau of Community Program Licensure and Certification | Division of home health 555 Walnut Street, 7th Floor, Suite 701 | Harrisburg, PA 17101 | | F | Form Page 1 of 2 Initial application for home health Agency License Identifying Information Name of Entity: D/B/A: Mailing Address: Street City Zip Code Site Address: Street City Zip Code County: Telephone: Fax: Include area code Email Address: Contact Person: Days and Hours of Operation.

3 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours List of Geographic Service Areas by County Please indicate if the agency will have a 24-hour on-call : An on-site inspection by surveyors will occur during the business hours submitted. Payment A Check or Money Order Payable to Commonwealth of Pennsylvania for the amount of the fee must accompany this application . Currency is not acceptable. The regular fee per license is $250. application Form Page 2 of 2 Mail the completed and signed original application with a check or money order to:Pennsylvania Department of health Division of home health 555 Walnut Street, 7th Floor, Suite 701 Harrisburg, PA 17101 IMPORTANT: Please retain a copy of your entire packet for your records.

4 Agreement application is made to operate a home health Agency in accordance with Chapter 8 of the health care Facility Act (35 et. seq.). application includes Initial application Form with payment, Civil Rights Survey, Information requested of health care Providers applying for a license, Documentation Required for Initial home health License, and Password Agreement form. I agree that all of the identifying information on this form and information furnished on the aforementioned attached documents and all other materials submitted are complete and true.

5 I understand that incomplete or inaccurate information IS REASON FOR DENYING THE ISSUANCE OF A LICENSE. I further agree to conduct said facility in accordance with the laws of the Commonwealth of Pennsylvania and with the rules and regulations of the Department of health . Affirmation The undersigned hereby affirms that the foregoing information is true and correct to the best of said persons knowledge, information and belief; said affirmation being made subject to the penalties prescribed by 18 Pa. 4904 (unsworn falsifications to authorities).

6 Authorized Representative s Signature* Date Print Name of Authorized Representative s Date *Authorized Representative the individual within the Applicant organization with the legal authority to giveassurances, make commitments, enter into contracts, and execute documents on behalf of the Applicant, includingthis application . The signature of the Authorized Representative certifies that commitments made on thisApplication will be honored and ensures that the Applicant agrees to conform to applicable law and type or print legibly Provider/License Number.

7 Password Agreement I, (Name) hereby certify that effective (date became administrator), I am the Administrator/Director/Chief Executive Officer for (Facility Name) and that I am responsible for submitting a Plan of Correction in response to deficiencies cited by the Pennsylvania Department of health on CMS Form 2567. acknowledge receipt of the facility identification number and my individual password (whichwill be provided after receipt of this agreement) from the Pennsylvania Department of agree to maintain the confidentiality of both the facility identification number and my recognize and acknowledge that the use of my password to electronically submit a Plan ofCorrection, in response to deficiencies cited on a CMS Form 2567, identifies me as the signer ofthe Plan of further recognize and acknowledge that the use of my password, in conjunction with thesubmission of a Plan of Correction.

8 Authorizes the Pennsylvania Department of health toconclusively accept that electronic Plan of Correction as my authorized have had the opportunity to review this Agreement and hereby agree to the above statements. Email address Signature of Administrator/CEO/Director Signature of Witness Date Return to: Division of home health 555 Walnut Street, 7th Floor, Suite 701 Harrisburg, PA 17101 Or Fax to: Commonwealth of Pennsylvania Department of health Division of home health Civil Rights Survey Agency Name: Note: The word discrimination shall be understood to mean discrimination on the basis of race, color, national origin, religious creed, ancestry, sex, age, or handicap as used in the Pennsylvania Human Relations Act of 1955, as amended.

9 1. Is a non-discrimination policy which states services are provided, referrals are made, andemployment actions are made without regard to race, sex, color, national origin, ancestry,religious creed, handicap, or age posted conspicuously in the agency?Yes If yes, provide a copy and indicate where posting are located. No If no, state what corrective steps will be taken to assure a non-discrimination policy is developed and posted. Note: When any change in policy, a signed and dated copy of the revised policy shall be submitted to the State Survey Agency within 30 days of the effective change.

10 The agency include the non-discrimination policy in brochures, media notices, and posters?Yes If yes, identify publications and media communications means used. No If no, state what corrective steps will be taken. methods and materials used to orient patients and staff to civil rights Are patients/consumers and staff informed that complaints of discrimination may be filed withthe Office of Equal Opportunity, Pennsylvania Department of health , and/or the PennsylvaniaHuman Relations Commission?Yes If yes, explain the contents of the information and how it is disseminated.